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        <p>听课时间：20190808<br>微贴面与常规贴面粘接等不一样。<br>第一部分 微贴面概述<br>1.起源及文献回顾<br>a.1964年，牙外伤断片粘接，断冠再接。<br>b.1990年，学者确认断牙再接的效果。<br>c.第一例微贴面病例报道。<br>d.2011年，微贴面完全覆盖唇面病例（强调粘接精修抛光的重要性）<br>e.薄的微贴面修复上颌切牙四类洞的病例<br>f.5年回访的病例。<br>2.微贴面的定义<br>部分覆盖一个或多个牙齿表面的陶瓷修复体。<br>3.微贴面技术的四项基本要求<br>1)待修复的牙齿色度必须理想，因为微贴面的厚度薄，不能遮盖牙齿颜色。<br>2)通过观察修复空间，微贴面只能用于替代或增量牙齿结构的病例。<br>3)必须评估微贴面的就位道，检查是否需要去除小倒凹。<br>4)技工室必须掌握微贴面的制作技术。<br>（建议粘接面仅限为牙釉质以便承受咬合力时牙齿结构不变形。）<br>第二部分 适应症和临床优势<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/005/01.png"><br>第三部分 禁忌症<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/005/02.png"><br>临床困难及原因<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/005/03.png"><br>第四部分 微贴面的临床过程<br>1.病例选择<br>a.主诉及评估四项要求<br>b.考虑微贴面的适应证<br>c.考虑禁忌症及相对禁忌症。<br>d.取PVS（加成型硅橡胶）印模和拍摄口内照片制作蜡型。<br>2.治疗计划测试（诊断蜡型——诊断饰面的详细过程）<br>a.诊断蜡型（应该由医生完成）<br>1)诊断分析<br>2)美学评估<br>b.诊断饰面<br>1)向患者预览治疗结果<br>2)引导精准的微小预备<br>诊断饰面是蜡型在口内试戴的过程，是美学修复治疗的基础。<br>c.需要的材料：略<br>d.诊断饰面的步骤流程<br>1)硅胶制取初印模（轻重体都使用）<br>2)灌模，制作代型<br>a)修整雏形代型（灌两个模型，一个寄存，一个做蜡型。防止法律风险）<br>b)涂布分离剂后固定<br>c)翻制牙槽骨模型<br>d)牙槽骨模型完成<br>e)校对牙槽骨模型<br>3)模型上制作蜡型<br>4)完整最终蜡型<br>5)翻制硬质硅胶阴模（轻体+重体）<br>a)首选PVS材料<br>b)轻体+重体复制所有细节。<br>c)超过非蜡型牙位1-2颗牙。<br>d)大范围蜡型时可增加舌侧面积。<br>6)修整硅胶阴模及诊断饰面完成<br>a)颊侧厚度至少4mm<br>b)用浮石和橡皮杯清洁牙齿<br>c)先去除混合头前端至少8mm双丙烯酸树脂再将其注入硅橡胶壁内。慢慢注射，排除气泡。<br>d)使用注射枪自切端沿切-颈方向向硅橡胶壁内注射双丙烯酸树脂材料<br>e)以特定的方向垂直带入硅橡胶壁<br>f)按压硅橡胶壁颈部一分钟<br>g)一分钟后去除多余材料<br>h)用酒精纱布擦去未固化层抛光（涂光亮漆）<br>i)用染料进行特行性染色（可选）<br>j)干毡轮抛光。<br>4)比色<br>a)清洁牙齿，去除牙石，特别是邻面和腭面区域<br>b)尽可能在取模前一次复诊洁牙，避免出血影响取模。<br>c)应该在治疗引起牙齿发生脱水之前第一次取模时进行比色。<br>比色步骤：<br>①确定牙齿清洁，无牙石<br>②漂白后等待7天牙色稳定<br>③最好在上午10点至下午2点之间比色，照片取景包含唇与皮肤，观察光线下各部分之间的相互作用。<br>④接触牙齿水平放置比色板，并与牙齿长轴平行。<br>5)选择性牙体预备<br>a)去除轴嵴以及切端的锐利线角（仅限于釉质）<br>b)去除就位道的倒凹（精细的金刚砂）<br>c)光滑表面（红黄抛光碟）<br>6)排龈和印模(从材料到步骤细节）<br>a)非关闭间隙的微贴面不排龈保持牙龈原始状态。<br>b)关闭间隙的微贴面排龈扩展颈缘建立新的轮廓。<br>c)使用PVS<br>d)采用双相两次法。<br>取模过程及细节<br>①确保牙龈健康，无出血，取模前15天内使用氯己定漱口<br>②确保托盘大小足够容纳印模材料，第一磨牙颊侧与托盘壁之间必须有8mm空间容纳印模材料。<br>③根据牙周生物型选用排龈线，薄龈生物型采用细排龈线。<br>④涂止血剂（现在少用了）<br>⑤两步法取模：装有高粘度硅橡胶材料的托盘口内就位后，前两分钟内移动托盘，为低粘度印模材料创造空间。<br>⑥取出高粘度印模材料以及第二个排龈线。<br>⑦在口内及托盘上注射低粘度印模材料。<br>第五部分 微贴面的材料选择<br>1.长石质陶瓷和铸瓷的特点分析<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/005/04.png"><br>2.二硅酸锂陶瓷微贴面的适应症及原因<br>a.压铸或切割。（只能用铸压式的）<br>b.薄的压铸陶瓷为单色透明度高。<br>c.明度低半透明<br>d.常用于咬合面和需要牙合引导腭面修复<br>3.长石质陶瓷<br>a.分层堆塑<br>b.很薄也可具有遮色性。<br>c.可以调整明度和半透明度<br>d.常用于微贴面和前牙唇侧<br>第六部分 微贴面的试戴与粘结<br>1.试戴及粘接所需要的材料<br>略<br>2.试戴的要点<br>a.清洁牙齿<br>b.观察就位道<br>c.试邻接点<br>d.试色糊剂（建议用水）<br>e.完成试戴<br>3.粘接水门汀的选择<br>高流动性，不含叔胺的。纯光固化的。<br>4.粘接注意事项<br>a.就位道多易错位。<br>最好让技师做硅橡胶导板。<br>b.固化前去除多余水门汀。<br>c.多角度观察<br>d.多颗微贴面时中切牙为先，逐颗粘，关闭间隙的两颗牙一起粘。<br>5.粘固的流程——修复体界面<br>a.HF处理（长石质90-120s，铸瓷20s）<br>b.彻底冲洗<br>c.干燥见白垩色（不宜超声荡洗）<br>d.磷酸处理去除白垩色粉末。<br>e.涂1遍硅烷，等5分钟。吹干（吹去缩合反应生成的水分子）<br>f.一般不建议涂粘接剂（常规贴面可涂，因为很多粘接剂有黄色的成分）<br>g.涂布树脂水门汀。<br>6.粘固的流程——牙齿界面<br>a)清洁牙齿<br>b)排龈，橡皮障前牙用劈障技术。<br>c)酸蚀釉质<br>d)干燥釉质<br>e)涂布粘接剂（不用光固化）<br>第七部分：微贴面粘接后的精修和抛光<br>1.粘固后陶瓷界面的特点<br>a.粘固后外形，轮廓，边缘需要修整<br>b.时机：粘固后可单独约诊精修。<br>c.粘固后的界面分析<br>2.不同界面的精修步骤<br>a.精细修整的工具<br>放大设备（4倍起）<br>车针（锥形柱状，尖形细的）<br>手机：电动手机<br>b.不同界面的修整方式<br>1)垂直界面：龈颌向，要将车针与水平方向一致垂直打磨。由龈方向切端。转速2万。干磨，气冷。别喷水，保持视野清晰。<br>2)水平界面：车针龈颌向摆放，水平向移动。<br>3)混合界面（切端）：混合磨。<br>c.抛光完成<br>EVE陶瓷抛光系统。<br>由粗到细。<br>3.抛光完成<br>(实操，略了）<br>总结：没做过，做一般了解吧。适应症：恢复咬合，充填四类五类洞，关闭间隙，修补瓷修复体。禁忌症：基牙变色，无就位道，釉质不足牙本质暴露，咬合异常。优点：微创。缺点：不能改变颜色，戴牙时易碎，对粘接要求高。操作粘接步骤：跟嵌体差不多。只是要做mock-up，印模都用双相二次法。一个技巧：取模时初模放入后在嘴里晃几下，形成空间，硬了以后再打终模。这种会不会比初模上放薄膜然后直接一次取终模要好？试一下吧。粘接完要抛光，先用黄标车针，垂直界面，水平界面，混合界面（切端）都要抛，然后用抛光系统精抛。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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